A survival analysis of benign prostatic hyperplasia procedure complications

This thesis presents a complication risk comparison of the most used surgical interventions for benign prostatic hyperplasia (BPH). The investigated complications are the development of either a post-surgery BPH recurrence (reoperation), an urethral stricture or stress incontinence severe enough to require a surgical procedure for their treatment. The analysis is conducted with survival analysis methods on a data set of urological patients sourced from the Finnish Institute for Health and Welfare. The complication risk development is estimated with the Aalen-Johansen estimator and the effects of certain covariates on the complication risks is estimated with the Cox PH regression model. One of the regression covariates is the Charlson Comorbidity Index score, which attempts to quantify a disease load of a patient at a certain point in time as a single number. A novel Spark algorithm was designed to facilitate the efficient calculation of the Charlson Comorbidity Index score on a data set of the same size as the one used in the analyses here. The algorithm achieved at least similar performance to the previously available ones and scaled better on larger data sets and with stricter computing resource constraints. Both the urethral stricture and urinary incontinence endpoints suffered from a lower number of samples, which made the associated results less accurate. The estimated complication probabilities in both endpoint types were also so low that the BPH procedures couldn’t be reliably differentiated. In contrast, BPH reoperation risk analyses yielded noticeable differences among the initial BPH procedures. Regression analysis results suggested that the Charlson Comoborbidity Index score isn’t a particularly good predictor in any of the endpoints. However, certain cancer types that are included in the Charlson Comorbidity Index score did predict the endpoints well when used as separate covariates. An increase in the patient’s age was associated with a higher complication risk, but less so than expected. In the urethral stricture and urinary incontinence endpoints the number of preceding BPH operations was usually associated with a notable complication risk increase

Delirium in Long Term Care Rehabilitation Residents: A Correlational Retrospective Study

Abstract Background: Delirium is associated with devastating outcomes, cognitive loss, decreased function and an increase risk of mortality which affects patients and places a heavy burden on family and the healthcare system. The purpose of this study was to describe the relationship between select demographics, clinical characteristics, CHART- DEL-derived delirium diagnosis and ICD-10 coded discharge delirium diagnoses among Long Term Care (LTC) rehabilitation residents. Method: A retrospective correlational design from174 LTC rehabilitation residents age 65 years or older using EMR and hard copy charts. The setting was a Southern California community hospital-based 100-bed LTC. Abstracted data included demographic characteristics (age, gender, race), principal admitting diagnosis, admission source, discharge disposition, medication management (polypharmacy, psychotropic medications duration), presence of dementia, CHART-DEL-derived delirium diagnoses documented delirium symptoms and International Classification of Disease, 10th revision (ICD 10) coded delirium, LOS, Charlson score (comorbidities). Statistical methodology included: descriptive statistics for demographic and other variable data. Chi square for relationship between delirium and the independent variables. ANOVA described the difference between the variables. Multiple logistic regression determined the odds of having a delirium diagnosis (by either approach with separate models) based upon gender, race, principle admitting diagnosis, polypharmacy, dementia, age, LOS, Charlson score (comorbidities), and psychotropic medications duration. Results: Majority residents were female, white, average age 80.6, 99.4% acute care admissions, and 96.6% had polypharmacy. Psychotropic duration mean was 9.5 days, LOS 14.7 days, and 64.9% discharged home with home health. More delirium identified with CHART-DEL-derived delirium diagnoses (24.9%) compared to ICD-10 code diagnosis (5.2%). The Charlson score (comorbidity) was related to delirium in both models (CHART-DEL-derived p = .044; ICD-10 code p = .002), while LOS additionally explained variance, but only in CHART-DEL-derived delirium model. Conclusions: The daily use of a delirium-screening instrument by the healthcare team could assist with delirium identification sooner and implement appropriate interventions. This then could decrease negative outcomes of delirium, improve satisfaction among family and staff and increase resident quality of care and safety

Surgical complications: a hospital-wide registering system and factors associated with surgical complications

ABSTRACT The primary aim of the present thesis was to study how surgical quality can be measured in a single hospital, by creating and describing a simple and usable tool for registering outcomes data based on severity of complications. First, a systematic review of the subject was conducted. The evaluation of the articles revealed wide methodological heterogeneity in the classification and categorization of complications and data collection methods. Subsequently, a pilot hospital-wide surgical complication register was created and implemented in Satasairaala, Pori, Finland. Perioperative data related to all adult general and orthopedic surgery procedures for 3 years (2016–2018) were included in the study. Complications were recorded according to a modified Clavien–Dindo classification, and the preoperative risk factors were compiled based on the literature and coded as numerical measures. The overall complication rate in 4529 patients was 17.2% (95% confidence interval (CI) 16.1–18.3), and 4.6% (95% CI 4.0–5.2) were graded as major complications. The results also showed that only a few patient-related risk factors were sufficient to account for the case mix. Further aims of this thesis were to study factors associated with patient education and patient perceptions on surgical quality, and their association with surgical complications. Adult patients undergoing surgical operations were studied by questionnaires in 2016–2017 in Satasairaala, Pori. The results indicate that the information needs of the patients vary individually. The level of received information by patient education and the patient perception on quality of care may have an association with reported surgical complications. KEYWORDS: surgery, quality improvement, health policy, health services management, performance measures, quality in healthcare, patient safety, human resource management, human factors, real-world effectivenessTIIVISTELMÄ Tämän tutkimuksen ensisijaisena kohteena on kirurgisten komplikaatioiden mittaaminen sairaalatasolla. Väitöskirjan tavoitteena oli luoda kaikki kirurgian alat kattava komplikaatioita mittaava rekisteri, joka hyödyntää olemassa olevaa sähköistä sairaskertomusjärjestelmää. Järjestelmällisen katsauksen avulla selvitettiin ensin tieteellisessä kirjallisuudessa julkaistut tutkimukset olemassa olevista vastaavista rekistereistä sekä ne potilaaseen ja kirurgiseen toimenpiteeseen liittyvät tekijät, joiden tiedetään olevan yhteydessä kirurgisiin komplikaatioihin. Järjestelmällinen kirjallisuuskatsaus osoitti, että tiedonkeruumenetelmissä ja komplikaatioiden luokittelussa on maailmalla suurta vaihtelua. Satasairaalaan luotiin pilottihankkeena koko kirurgian klinikan laajuinen komplikaatiorekisteri, ja tässä väitöskirjassa esitellään tulokset kolmen vuoden ajalta (2016–2018). Komplikaatioita todettiin 17.2 %:lla (95 %CI 16.1–18.3) 4529 leikatusta potilaasta. Näistä 4.6 % (95 %CI 4.0–5.2) luokiteltiin vakaviksi. Tulosten mukaan potilaskohtaisen riskin määrittämiseen saattaa riittää muutama kliininen mittari. Lisäksi tässä väitöskirjassa tutkittiin, missä määrin potilaan informointi ja ohjaus sekä potilaan kokemus hoidon laadusta ovat yhteydessä komplikaatioiden esiintyvyyteen kotiutuksen jälkeen. Tulosten mukaan potilaskohtaisen ohjauksen tarve vaihtelee yksilöllisesti, ja potilasohjauksella ja potilaan kokemalla laadulla saattaa olla yhteyttä leikkauksesta toipumiseen ja komplikaatioiden esiintymiseen. Tässä väitöskirjassa kuvataan koko aikuiskirurgian kattava komplikaatioita mittaava järjestelmä, sekä tuodaan esiin kirurgisen hoidon osa-alueita, joilla saattaa olla yhteyttä hoidon lopputulokseen, esimerkkeinä potilasohjaus ja potilaan kokema laatu. AVAINSANAT: kirurgia, laadun parantaminen, terveyspolitiikka, terveydenhuoltohallinto, dokumentointi, potilasturvallisuus, terveydenhuollon laatu, henkilöstöhallinto, inhimilliset tekijät, arkivaikuttavuu

Racial and Ethnic Differences in Receipt of Immediate Breast Reconstruction Surgery: Do Hospital Characteristics Matter?

Immediate Breast Reconstruction Surgery (IBRS) is associated with better quality of life among women who undergo a mastectomy. Despite insurance coverage for IBRS, utilization of IBRS remains low. Data from publicly available sources for 2010-2012 are used to examine the association between hospital characteristics receipt of IBRS by patients. Minority-serving status, low bed size, for-profit ownership, non-teaching status, high competition, low density of plastic surgeons in the market and non-metropolitan location are associated with lower likelihood of receipt of IBRS. Racial and ethnic minorities are less likely to receive IBRS. A mixed effects logistic regression model with interactions between Black/Hispanic race/ethnicity and hospital variables is estimated to examine whether certain hospital characteristics are associated with disparately low receipt of IBRS for racial and ethnic minorities. Minority-serving hospitals located in markets with a higher density of plastic surgeons and higher competition characteristics are associated with disparately low receipt of IBRS for racial and ethnic minorities. In order to reduce racial/ ethnic differences in receipt of IBRS, it is important to understand which factors contribute the most to these differences. Fairlie decomposition is used to examine the contribution of multi-level factors to racial and ethnic differences in receipt of IBRS. Racial and ethnic differences in being Medicaid insured, residing in low-income neighborhoods and receiving care at minority-serving hospitals are the three largest contributors to racial and ethnic differences in receipt of IBRS. The results from this study have significant implications for access to IBRS among racial and ethnic minority patients